Keeping the front door open: ensuring access to primary care for all in Canada

Access to a regular primary care physician among young people with early psychosis in Ontario, Canada

AIM

Access to a primary care physician in early psychosis facilitates help-seeking and engagement with psychiatric treatment. We examined access to a regular primary care physician in people with early psychosis, compared to the general population, and explored factors associated with access.

METHODS

Using linked health administrative data from Ontario (Canada), we identified people aged 14-35 years with a first diagnosis of nonaffective psychotic disorder (n = 39 449; 2005-2015). We matched cases to four randomly selected general population controls based on age, sex, neighbourhood, and index date (n = 157 796). We used modified Poisson regression to estimate prevalence ratios (PR) for access to a regular primary care physician in the year prior to first diagnosis of psychotic disorder, and the sociodemographic and clinical factors associated with access.

RESULTS

A larger proportion of people with early psychosis had a regular primary care physician, relative to the general population (89% vs. 68%; PR = 1.30, 95%CI = 1.30-1.31). However, this was accounted for by a higher prevalence of comorbidities among people with psychosis, and this association was no longer present after adjustment (PR = 0.97, 95%CI = 0.97, 0.98). People with early psychosis who were older, male, refugees and those residing in lower income or high residential instability neighbourhoods were less likely to have a regular primary care physician.

CONCLUSION

Approximately one in ten young people with early psychosis in Ontario lack access to a regular primary care physician. Strategies to improve primary care physician access are needed for management of physical comorbidities and to ensure continuity of care.

Accessing care within team-based models of primary care for the management of chronic low back pain in Ontario, Canada: a qualitative study of patient experiences

PURPOSE

To understand experiences accessing care within team-based primary care models among adults with chronic low back pain (LBP).

MATERIALS & METHODS

We conducted an interpretive description qualitative study and collected data using one-to-one semi-structured interviews. Participants were recruited from publicly funded, team-based primary care models in Ontario, Canada.

RESULTS

We completed interviews with 16 adults with chronic LBP (9 women; median age of 66). Participants expressed a desire to access care from team-based models of primary care in hopes of alleviating pain and its impacts on daily life. Due to no direct out-of-pocket costs, co-location of healthcare providers, and the use of technology and virtual care, participants described an ease of accessing interprofessional care within team-based primary care models. Finally, participants described experiences with and expectations for timely access to care, being heard and understood by healthcare providers, and receiving coordinated care by an interprofessional team.

CONCLUSIONS

Adults living with chronic LBP described overall positive experiences and specific expectations when accessing care within team-based models of primary care, whereby they experienced an ease of accessing interprofessional care with the hope of alleviating pain and its impacts. Results may be transferable to other chronic pain conditions and health system contexts.

A shifting terrain: Understanding the perspectives of walk-in physicians on their roles amid worsening primary care access in Ontario, Canada

BACKGROUND

High-quality primary care is associated with better health outcomes and more efficient and equitable health system performance. However, the rate of primary care attachment is falling, and timely access to primary care is worsening, driving many patients to use walk-in clinics for their comprehensive primary care needs. This study sought to explore the experiences and perceived roles and responsibilities of walk-in physicians in this current climate. Methods: Qualitative interviews were conducted with nineteen physicians currently providing walk-in care in Ontario, Canada between May and December 2022.

RESULTS

Limited capacity for continuity and comprehensiveness of care were identified as major sources of professional tension for walk-in physicians. Divergent perspectives on their roles were anchored in how physicians viewed their professional identity. Some saw providing continuous and comprehensive care as an infringement on their professional role; others saw their professional role as more flexible and responsive to population needs. Regardless of their professional identity, participants reported feeling ill-equipped to manage the swell of unattached patients, citing a lack of time, resources, connectivity to the system, and remuneration flexibility. Conclusions: As practice demands of walk-in clinics change, an evolution in the professional roles and responsibilities of walk-in physicians follows. However, the resources, structure, and incentives of walk-in care have not evolved to reflect this, leaving physicians to set their own professional boundaries with patients. This results in increasing variations in care and confusion across the primary care sector around who is responsible for what, when, and how.

Identifying strategies to support implementation of interprofessional primary care teams in Nova Scotia: Results of a survey and knowledge sharing event

BACKGROUND

Interprofessional primary care teams (IPCTs) work together to enhance care. Despite evidence on the benefits of IPCTs, implementation remains challenging. This research aims to 1) identify and prioritize barriers and enablers, and 2) co-develop team-level strategies to support IPCT implementation in Nova Scotia, Canada.

METHODS

Healthcare providers and staff of IPCTs were invited to complete an online survey to identify barriers and enablers, and the degree to which each item impacted the functioning of their team. Top ranked items were identified using the sum of frequency x impact for each response. A virtual knowledge sharing event was held to identify strategies to address local barriers and enablers that impact team functioning.

RESULTS

IPCT members (n = 117), with a mix of clinic roles and experience, completed the survey. The top three enablers identified were access to technological tools to support their role, standardized processes for using the technological tools, and having a team manager to coordinate collaboration. The top three barriers were limited opportunity for daily team communication, lack of conflict resolution strategies, and lack of capacity building opportunities. IPCT members, administrators, and patients attended the knowledge sharing event (n = 33). Five strategies were identified including: 1) balancing patient needs and provider scope of practice, 2) holding regular and accessible meetings, 3) supporting team development opportunities, 4) supporting professional development, and 5) supporting involvement in non-clinical activities.

INTERPRETATION

This research contextualized evidence to further understand local perspectives and experiences of barriers and enablers to the implementation of IPCTs. The knowledge exchange event identified actionable strategies that IPCTs and healthcare administrators can tailor to support teams and care for patients.

Barriers and enablers to implementing interprofessional primary care teams: a narrative review of the literature using the consolidated framework for implementation research

BACKGROUND

Interprofessional primary care teams have been introduced across Canada to improve access (e.g., a regular primary care provider, timely access to care when needed) to and quality of primary care. However, the quality and speed of team implementation has not kept pace with increasing access issues. The aim of this research was to use an implementation framework to categorize and describe barriers and enablers to team implementation in primary care.

METHODS

A narrative review that prioritized systematic reviews and evidence syntheses was conducted. A search using pre-defined terms was conducted using Ovid MEDLINE, and potentially relevant grey literature was identified through ad hoc Google searches and hand searching of health organization websites. The Consolidated Framework for Implementation Research (CFIR) was used to categorize barriers and enablers into five domains: (1) Features of Team Implementation; (2) Government, Health Authorities and Health Organizations; (3) Characteristics of the Team; (4) Characteristics of Team Members; and (5) Process of Implementation.

RESULTS

Data were extracted from 19 of 435 articles that met inclusion/exclusion criteria. Most barriers and enablers were categorized into two domains of the CFIR: Characteristics of the Team and Government, Health Authorities, and Health Organizations. Key themes identified within the Characteristics of the Team domain were team-leadership, including designating a manager responsible for day-to-day activities and facilitating collaboration; clear governance structures, and technology supports and tools that facilitate information sharing and communication. Key themes within the Government, Health Authorities, and Health Organizations domain were professional remuneration plans, regulatory policy, and interprofessional education. Other key themes identified in the Features of Team Implementation included the importance of good data and research on the status of teams, as well as sufficient and stable funding models. Positive perspectives, flexibility, and feeling supported were identified in the Characteristics of Team Members domain. Within the Process of Implementation domain, shared leadership and human resources planning were discussed.

CONCLUSIONS

Barriers and enablers to implementing interprofessional primary care teams using the CFIR were identified, which enables stakeholders and teams to tailor implementation of teams at the local level to impact the accessibility and quality of primary care.

Thinking and Enacting the Patient Medical Home Under Pandemic Conditions: A Qualitative Study From Primary Care in Alberta, Canada

BACKGROUND

The COVID-19 (C19) pandemic shocked primary care systems around the world. Those systems responded by supporting patients in the community, and acute care facilities in crisis. In Canada, the Patient Medical Home (PMH) is a widely adopted care model that aims to operationalize the tenets and principles of Primary Health Care (PHC) as developed since the Alma-Ata Declaration. This paper describes how personnel working in and with Primary Care Networks (PCNs) in Alberta, Canada deployed the PMH model and its underlying PHC principles to frame and respond to the C19 shock.

METHODS

Using purposive and snowball sampling techniques, we interviewed 57 participants who worked in public health and primary care, including community-based family physicians. We used interpretive description to analyze the interviews.

RESULTS

PCN staff and physicians described how the PMH model was foundational to normal operations, and how C19 responses were framed by the patient-centric, team-delivered, and continuous care principles the model shares with PHC. Specifically, participants described ensuring access to care, addressing the social determinants of health, being patient centered, and redeploying and expanding PHC teams to accomplish these goals.

DISCUSSION

Delivering PHC through the PMH allowed physicians and allied health staff to deliver patient-centered, team-based, holistic bio-medical services to Albertans. In tailoring services to meet the specific social and health needs of the populations served by each PCN, healthcare providers were able to ensure relevant support remained available and accessible.

"The Cost in the Individual": Longitudinal Burnout Prevalence Among Pediatric Emergency Physicians Through 9 Months of the COVID-19 Pandemic

OBJECTIVES

Emergency medicine (EM) confers a high risk of burnout that may be exacerbated by the COVID-19 pandemic. We aimed to determine the longitudinal prevalence of burnout in pediatric EM (PEM) physicians/fellows working in tertiary PEM departments across Canada and its fluctuation during the pandemic.

METHODS

A national mixed-methods survey using a validated 2-question proxy for burnout was distributed monthly through 9 months. The primary outcome was the trajectory in probability of burnout, which was examined as both emotional exhaustion (EE) and depersonalization (DP), EE alone, and DP alone. Secondary outcomes investigated burnout and its association with demographic variables. Quantitative data were analyzed using logistic regression for primary outcomes and subanalyses for secondary outcomes. Conventional content analysis was used to analyze qualitative data and generate themes.

RESULTS

From February to October 2021, 92 of 98 respondents completed at least 1 survey, 78% completed at least 3 consecutive surveys, and 48% completed at least 6 consecutive surveys. Predicted probability of EE was bimodal with peaks in May (25%) and October (22%) 2021. Rates of DP alone or having both EE and DP were approximately 1% and stable over the study period. Mid-career physicians were at lower risk of EE (odds ratio, 0.02; 95% confidence interval, 0-0.22) compared with early-career physicians. Underlying drivers of burnout were multifaceted.

CONCLUSIONS

Our study suggests that increased COVID-19 case burden was correlated with EE levels during the third and fourth waves of the pandemic. Emotional exhaustion was worsened by systemic factors, and interventions must target common themes of unsustainable workloads and overwhelming lack of control.

Characterizing the Palliative Care Physician Workforce: A Retrospective Cross-Sectional Study With Population-Based Data in Ontario, Canada

OBJECTIVES

Because of an increasing need to build capacity for end-of-life care, improving access to palliative care is a priority. Where a physician practices (eg, hospital, outpatient clinic, home) directly relates to the type of service and the stage of illness at which care is provided. In this study, we describe the physician palliative care specialist workforce and the settings of care within which they practice.

DESIGN

A retrospective cohort.

SETTING AND PARTICIPANTS

All physicians with palliative care billing codes who were practicing between April 1, 2018, and March 31, 2019, in Ontario, Canada.

METHODS

Descriptive statistics of physician billing location and frequency using linked population-based health administrative data.

RESULTS

We identified 8883 physicians who provided palliative care during the study period. Of those, 723 (8.1%) were classified as palliative care specialists (>10% of their billings encounters were palliative care). The majority (57.4%) of palliative care specialists worked in 1 setting more than 90% of their time, across home visits (27.1%), indirect care (22.4%), and office (7.9%). There were 61 palliative care specialists practicing in mixed locations who provided home visits, meaning 310 (42.9%) of the palliative care specialists delivered some home-based care.

CONCLUSIONS AND IMPLICATIONS

This research provides a comprehensive description of the current palliative care specialist physician workforce that can support efforts to build capacity for high-quality end-of-life care.

Cancer Screening Disparities Before and After the COVID-19 Pandemic

Importance

Breast, cervical, and colorectal cancer-screening disparities existed prior to the COVID-19 pandemic, and it is unclear whether those have changed since the pandemic.

Objective

To assess whether changes in screening from before the pandemic to after the pandemic varied for immigrants and for people with limited income.

Design, Setting, and Participants

This population-based, cross-sectional study, using data from March 31, 2019, and March 31, 2022, included adults in Ontario, Canada, the country's most populous province, with more than 14 million people, almost 30% of whom are immigrants. At both dates, the screening-eligible population for each cancer type was assessed.

Exposures

Neighborhood income quintile, immigrant status, and primary care model type.

Main Outcomes and Measures

For each cancer screening type, the main outcome was whether the screening-eligible population was up to date on screening (a binary outcome) on March 31, 2019, and March 31, 2022. Up to date on screening was defined as having had a mammogram in the previous 2 years, a Papanicolaou test in the previous 3 years, and a fecal test in the previous 2 years or a flexible sigmoidoscopy or colonoscopy in the previous 10 years.

Results

The overall cohort on March 31, 2019, included 1 666 943 women (100%) eligible for breast screening (mean [SD] age, 59.9 [5.1] years), 3 918 225 women (100%) eligible for cervical screening (mean [SD] age, 45.5 [13.2] years), and 3 886 345 people eligible for colorectal screening (51.4% female; mean [SD] age, 61.8 [6.4] years). The proportion of people up to date on screening in Ontario decreased for breast, cervical, and colorectal cancers, with the largest decrease for breast screening (from 61.1% before the pandemic to 51.7% [difference, -9.4 percentage points]) and the smallest decrease for colorectal screening (from 65.9% to 62.0% [difference, -3.9 percentage points]). Preexisting disparities in screening for people living in low-income neighborhoods and for immigrants widened for breast screening and colorectal screening. For breast screening, compared with income quintile 5 (highest), the β estimate for income quintile 1 (lowest) was -1.16 (95% CI, -1.56 to -0.77); for immigrant vs nonimmigrant, the β estimate was -1.51 (95% CI, -1.84 to -1.18). For colorectal screening, compared with income quintile 5, the β estimate for quntile 1 was -1.29 (95% CI, 16 -1.53 to -1.06); for immigrant vs nonimmigrant, the β estimate was -1.41 (95% CI, -1.61 to -1.21). The lowest screening rates both before and after the COVID-19 pandemic were for people who had no identifiable family physician (eg, moving from 11.3% in 2019 to 9.6% in 2022 up to date for breast cancer). In addition, patients of interprofessional, team-based primary care models had significantly smaller reductions in β estimates for breast (2.14 [95% CI, 1.79 to 2.49]), cervical (1.72 [95% CI, 1.46 to 1.98]), and colorectal (2.15 [95% CI, 1.95 to 2.36]) postpandemic screening and higher uptake of screening in general compared with patients of other primary care models.

Conclusions and Relevance

In this cross-sectional study in Ontario that included 2 time points, widening disparities before compared with after the COVID-19 pandemic were found for breast cancer and colorectal cancer screening based on income and immigrant status, but smaller declines in disparities were found among patients of interprofessional, team-based primary care models than among their counterparts. Policy makers should investigate the value of prioritizing and investing in improving access to team-based primary care for people who are immigrants and/or with limited income.

Rates of Hospital-Based Care among Older Adults in the Community and Residential Care Facilities: A Repeated Cross-Sectional Study

OBJECTIVE

We examine annual rates of emergency department (ED) visits, hospital admissions, and alternate levels of care (ALC) days (ie, the number of days that an older adult remained in hospital when they could not be safely discharged to an appropriate setting in their community) among older adults.

DESIGN

Repeated cross-sectional study.

SETTING AND PARTICIPANTS

Linked, individual-level health system administrative data on community-dwelling persons, home care recipients, residents of assisted living facilities, and residents of nursing homes aged 65 years and older in Ontario, Canada, from January 1, 2013, to December 31, 2019.

METHODS

We calculated rates of ED visits, hospital admissions, and ALC days per 1000 individuals per older adult population per year. We used a generalized linear model with a gaussian distribution, log link, and year fixed effects to obtain rate ratios.

RESULTS

There were 1,655,656 older adults in the community, 237,574 home care recipients, 42,600 older adults in assisted living facilities, and 94,055 older adults in nursing homes in 2013; there were 2,129,690 older adults in the community, 281,028 home care recipients, 56,975 older adults in assisted living facilities, and 95,925 older adults in nursing homes in 2019. Residents of assisted living facilities had the highest rates of ED visits (1260.692019 vs 1174.912013), hospital admissions (482.632019 vs 480.192013), and ALC days (1905.572019 vs 1443.032013) per 1000 individuals. Residents of assisted living facilities also had significantly higher rates of ED visits [rate ratio (RR) 3.30, 95% CI 3.20, 3.41), hospital admissions (RR 6.24, 95% CI 6.01, 6.47), and ALC days (RR 25.68, 95% CI 23.27, 28.35) relative to community-dwelling older adults.

CONCLUSIONS AND IMPLICATIONS

The disproportionate use of ED visits, hospital admissions, and ALC days among residents of assisted living facilities may be attributed to the characteristics of the population and fragmented licensing and regulation of the sector, including variable models of care. The implementation of interdisciplinary, after-hours, team-based approaches to home and primary care in assisted living facilities may reduce the potentially avoidable use of ED visits, hospital admissions, and ALC days among this population and optimize resource allocation in health care systems.

Social workers' formal and informal leadership in interprofessional primary care teams in Ontario, Canada

The development of interprofessional teams in primary care presents opportunities for social workers to take on new leadership positions. This study seeks to describe how social workers engaged in leadership roles in primary care during the COVID-19 pandemic. A cross-sectional on-line survey was disseminated to primary care social workers across Ontario, Canada, with a total of 159 respondents. Most respondents engaged in informal leadership roles and showcased a range of leadership skills promoting team collaboration and consultations, along with adapting to virtual care transitions. Findings suggest there needs to be intentional cultivation of social work leaders through supportive environments and training. Social workers in primary care have leadership capacity and are providing leadership to their primary care teams through formal and informal means. The leadership potential of social workers in primary care teams, however, is being underutilized and can be further developed.

Enterprise Healthcare Physician Services in Canada: An Environmental Scan

Employers in Canada are increasingly offering physician services to their employees through third-party "enterprise" virtual care platforms. In our environmental scan, we identified nine enterprise healthcare companies offering physician services to millions of Canadian employees via enterprise platforms. All platforms offered rapid access to virtual physician services. Some offered in-person visits, access to specialists, health system navigation and sharing of information with an employee's regular care provider. Almost half shared aggregate or de-identified health data with employers. These platforms provide rapid and convenient access to physician services but also disrupt the continuity of care, pose risks to employee privacy and expand two-tiered healthcare.

Primary care nursing competencies in Canadian undergraduate nursing programs: A national cross-sectional survey

AIM

To assess the extent to which Canadian undergraduate baccalaureate nursing programs have incorporated Canadian competencies for Registered Nurses in primary care into their curricula.

BACKGROUND

Canadian competencies for Registered Nurses in primary care have several benefits, including their ability to inform primary care education in undergraduate nursing programs and to assist in building a robust primary care nursing workforce.

DESIGN

We conducted a national cross-sectional survey of undergraduate baccalaureate nursing programs (n = 74).

METHODS

The survey was conducted between April-May 2022. We used a modified version of the "Community Health Nurses' Continuing Education Needs Questionnaire". Respondents indicated their level of agreement on a 6-point Likert scale with 47 statements about the integration of the competencies in their program (1 = strongly disagree; 6 = strongly agree).

RESULTS

The response rate was 51.4%. The overall mean across the six competency domains was 4.73 (SD 0.30). The mean scores of each domain ranged from 4.23 (SD 1.27) for Quality Assurance, Evaluation and Research to 5.17 (SD 0.95) for Communication.

CONCLUSIONS

There are gaps in how these competencies are included in undergraduate education programs and opportunities to strengthen education for this growing workforce in Canada.

Physician home visits to rostered patients during their last year of life: a retrospective cohort study

BACKGROUND

Physician home visits are associated with better health outcomes, yet most patients near the end of life never receive such a visit. Our objectives were to describe the receipt of physician home visits during the last year of life after a referral to home care - an indication that the patient can no longer live independently - and to measure associations between patient characteristics and receipt of a home visit.

METHODS

We conducted a retrospective cohort study using linked population-based health administrative databases housed at ICES. We identified adult (aged ≥ 18 yr) decedents in Ontario who died between Mar. 31, 2013, and Mar. 31, 2018, who were receiving primary care and were referred to publicly funded home care services. We described the provision of physician home visits, office visits and telephone management. We used multinomial logistic regression to calculate the odds of receiving home visits from a rostered primary care physician, controlling for referral during the last year of life, age, sex, income quintile, rurality, recent immigrant status, referral by rostered physician, referral during hospital stay, number of chronic conditions and disease trajectory based on the cause of death.

RESULTS

Of the 58 753 decedents referred in their last year of life, 3125 (5.3%) received a home visit from their family physician. Patient characteristics associated with higher odds of receiving home visits compared to office-based or telephone-based care were being female (adjusted odds ratio [OR] 1.28, 95% confidence interval [CI] 1.21-1.35), being 85 years of age or older (adjusted OR 2.42, 95% CI 1.80-3.26) and living in a rural area (adjusted OR 1.09, 95% CI 1.00-1.18). Increased odds were associated with home care referrals by the patient's primary care physician (adjusted OR 1.49, 95% CI 1.39-1.58) and referrals occurring during a hospital stay (adjusted OR 1.20, 95% CI 1.13-1.28).

INTERPRETATION

A small proportion of patients near the end of life received home-based physician care, and patient characteristics did not explain the low visit rates. Future work on system- and provider-level factors may be critical to improve access to home-based end-of-life primary care.

A North Star Vision: Results from a Deliberative Dialogue to Identify Policy Strategies to Improve Value in Healthcare

We hosted a deliberative dialogue with citizens (n = 3), policy researchers (n = 3), government decision makers (n = 3) and health system leaders (n = 3) to identify evidence-informed policy options to improve the value of Canadian healthcare. The analysis resulted in three themes: (1) the need for a vision to guide reforms, (2) community-based care and (3) community-engaged care. Results suggest the need for a new paradigm: community-focused health systems. Such a paradigm could serve as a North Star guiding healthcare transformation, improving value by aligning citizen and healthcare system goals, prioritizing spending on services that address the social determinants of health and improving quality and equity.